Synchronous bilateral adrenalectomy by midline incision: A reliable method for treatment of hypercortisolism.

We read an article entitled “Synchronous bilateral adrenalectomy by midline incision: A reliable method for treatment of hypercortisolism” by Tabatabaee et al.[1] with interest. We congratulate the authors for their good surgical outcomes. However, we would like to clarify a few points about simultaneous bilateral laparoscopic adrenalectomy (SBLA) for patients with medically uncontrollable Cushing's syndrome.

Laparoscopic adrenalectomy (LA) has significantly reduced the morbidity classically associated with open adrenalectomy. It is now the standard treatment of choice for most benign adrenal tumors, including unilateral Cushing's adenoma.[2] Even though the authors cited the complication rates of 9.5-12% during unilateral or SBLA, their references were from the earlier series.[1] In fact, those major complications were infrequently encountered in the experiences of ours and others,[2-5] with the mean conversion rate of only 0[4]-4.7%[3] during SBLA. In contrast, decreased blood loss, less postoperative pain, earlier resumption of oral feeding, and shorter hospital stays were achieved in patients undergoing either unilateral LA or SBLA.[3-5] We believe SBLA is technically feasible and safe under experienced hands.

Only 2 retrospective reports are available to compare simultaneous bilateral open and laparoscopic adrenalectomy for patients with Cushing's syndrome. Porpiglia et al. reported there was no significant difference in patients’ complications. The mean operative time was increased in patients receiving SBLA, while post-operative hospital stay was significantly longer in the open group.[6] Mikhail et al. also reported less blood loss, lower transfusion rate, and a trend toward a shorter hospital stay, but longer operative time in patients receiving SBLA compared to those with open adrenalectomy.[7]

Patients with Cushing's syndrome have an increased risk for complications due to high cortisol levels, poor clinical condition, and metabolic disturbances. The sizes of adrenal gland are usually larger because of chronic stimulation of adrenocorticotropic hormone, which also increases the difficulty of operation and risk of complications. Long open incisions may precipitate postoperative morbidity, especially in obese patients with impaired wound healing and reduced resistance to infection. Longer operation time might also be a risk factor associated with complications. The experienced surgeons can always start with the laparoscopic approach, and only dynamically convert to open approach if the dissection could not proceed smoothly, in order to achieve the task effectively without sacrificing the safety of the patients.

Although western guidelines emphasize on reduced amount of red meat intake, the recommendations should be localized based on regional health problems. It seems that a diet with high amounts of fruits, vegetables, whole grains, legumes, and low-fat dairy products is a healthy pattern for Iranian population. However, age, sex, and health status of subjects should be considered when providing recommendations toward red meat consumption.